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Home My WebLink AboutBLDX-25-1571 /-y Office Use Only (z, . C' Permit# X-aT-%5-4-1 f3 d ram_ t� 1- i ibl lmount nwrucnccsa .." 9 ��0RPO ,1r--' EXPRESS BUILDING PERMIT APPLICAT TOWN OF YARMOUTH RECEIVED !' Yarmouth Building Department s 1146 Route 28 NOV 2 6 2025 i South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUI I , -NT (� By __ CONSTRUCTION ADDRESS:_ �13 C U A V E- 4 1 I ` OWNER: 1 (A/1l\. k \oiU NAME PRESENT ADDRESS TEL. # CONTRACTOR:a MS PAIN• 31ALFiZEl AF_4.CALr,R, S, hEN/WS Gi I g'27 -31-1407 NAME MAILING ADDRESS TEL.# EMAIL:?AINE .bIZS 6 VAN al`(OM V Residential ❑Commercial Est.Cost of Construction$i al S.0 ep Homeowner is Applicant? Yes No 7 Home Improvement Contractor Lic.# 13Q 1 a1-3 Construction Supervisor Lic.# S O Sg g 4] 4 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares 1 9 Insulation Temporary Mobile Home Temporary Construction Trailer Demolition- Interior only Demolition Raze Structure Solar System ESS System Chimney Fence *Please submit utility disconnect letters for electric& gas-structures over 75 years old require historical review *The debris will be disposed of at: butt' 'Pj. 4) 1Z Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or�, at revocation of myy ense and for prosecution under M.G.L.Ch.268,Section I. � ev Applicant's Signature:C�i,� dj (mow 4 Date: I I/ ,/aS Owners Signature(or attachment) \I f44\ -)%` —r__\ Date: ►V)Ncrl Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents �. Office of Investigations wax .: "s Lafayette City Center ��_" 2 Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): e 1-//LS /'/F/Nf- 3 ,,LA it S Address:3i , LF, Ci rrIf1 4LF ),. Sovt/t b{NAr/S City/State/Zip:Soon/DhNNIS MA oa(6O Phone#: (,/7 g:-7 3L/4 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.2'I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.t 9. ['Building addition required.] 5.❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL yP 12.121 Roof repairs insurance required.]t c.152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] .Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:_ City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerhfy under the pair and penalties ofperjury that the information provided above is true and correct. Signature: .1 / Date: //- R 5--‘ - Phone#: 6 (7 q a-7 3L/`t j, Official use only. Do not write in this area,to be completed by city or town official. City or Town:_ Permit/License# Issuing Authority(check one): 10Board of Health 21:1 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5E'lumbing Inspector 6.DOther Contact Person: Phone#: ._, Commonwealth of Massachusetts Construction Supervisor Division of Occupational Licensure Unrestricted -Buildings of any use group which contain less than t----4. Board of Building Regulations and Standards 35,000 cubic feet(991 cubic meters) of enclosed space. Constotaforr§ifpgrvisor _ CS-058296, iffpires: 08/15/2027 :-.- CHRISTOPHP PAINE 31 ALFRED ' CALF DRIVE SOUTH DEN 1, MA 02660 =,•'-'• ,.• ' „ ? . Alr_-,- h --515;4e .)0 ,-)- 141/(10-‘ Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner Contact OPSI: (617)727-3200 or visit www.mass.gov/dpl/opsi Home improvement Contractor Re• istration Card Registration valid for use type, only before the expiration date. i Type: Individual 44 Number: 139223 Expiration: 08/25/2027 Issued tot i 13: 14 1 '-`._ $ CHRISTOPHER PAINE -' • .kr- g Christopher Paine 31 Alfred Metcalf S. Dennis, MA 02660 :17a4 1°,', & t 0 Layia R. Office of Consumer Affairs&Business Regulation Busin L.ztealz.,atza2=1.3.,.12110-2012 D'Emilia -05=s1MVISIZ7"..V....ux.4,144.=t) y